"I no longer wish to parent this child."
When 7-year-old Justin Hansen, whose name used to be Artyom Savelyev, was sent back to his native Russia this month with that note from his American adoptive mother, much of the ensuing criticism focused on the U.S. side of the matter. Some said that Justin's adoptive parents were not equipped to care for an allegedly disturbed and violent child and that they had failed to seek proper professional help. Others blamed the questionable practices of some U.S. adoption agencies.
But there is no doubt that families adopting children from Russia face unique challenges. In particular, Russian orphans suffer from psychological disorders at much higher rates than do orphans in many other countries. Last year, sociologists reported in the journal Pediatrics that Russian and eastern European adoptees were three to seven times more likely to have mental problems than Chinese and Korean adoptees. Philip Cohen, one of the study's authors, speculated to me that this might be because of high rates of fetal alcohol syndrome in former Eastern Bloc nations.
Yet at least some of the blame for the children's problems must be placed on flawed child-rearing practices common in Russian orphanages. These facilities offer a time capsule of a medicalized approach to child-rearing that was popular in the Unites States decades ago, before the critical importance of children's attachment to their caregivers was widely recognized and before we realized how damaging orphanages can be.
My colleague Richard Moriarty, a pediatrician and expert on international adoptions, recently traveled to an orphanage in Russia's Pskov province, where he witnessed an odd scene. More than a dozen infants wrapped tightly in blankets were lined up in cribs, observed by staff members through a series of glass windows. The room was uncomfortably warm and eerily silent, since none of the babies bothered to make any effort at vocalization. Occasionally, Moriarty told me, the infants were taken out for walks in strollers, but even then each was positioned to face away from the person pushing him. Staff members almost never held or cuddled the babies. "They didn't want the kids to get attached to people," Moriarty recalled. The problem wasn't that the children were neglected: They were kept fastidiously clean and were well groomed and well fed. The problem was that they were bereft of normal human contact.
Charles Nelson, a professor at Harvard Medical School who has studied and worked closely with Romanian orphanages for more than a decade, told me that although the caregivers he encountered there were well-meaning, they "raised kids in a way that was devoid of any affect." And Lisa Albers, a pediatrician at Children's Hospital Boston who studies international adoption, said that "Russian child welfare is still wedded to the medical model" -- meaning that it focuses on nutrition and cleanliness, not nurturing.
Russian orphans don't typically suffer from a deficit of medical care: If anything, physicians tend to overdiagnose them with dozens of labels, such as intestinal dysbacteriosis, pyramidal insufficiency and spastic tetraparesis, which have no meaning to my American colleagues (who, upon examining the children, often find them to be healthy).
All this would sound very familiar to observers of institutionalized children in the United States in the first half of the 20th century. Worried about the risk of infection, hospitals prohibited parents from visiting their ill children for more than one hour a week, and infants received minimal handling. In 1910, for example, homesick kids who cried too much at Massachusetts General Hospital were moved into isolation wards.
This approach wasn't limited to hospitals; it went to the heart of beliefs about child development in the early decades of the last century. At that time, an accidental alliance -- pediatricians trying to reduce infections and psychologists warning about overdependence -- encouraged parents and other caregivers to treat kids just as today's Russian orphanages do.
As Deborah Blum has written in "Love at Goon Park," her history of psychologist Harry Harlow's work on infant development, parenting books from the 1920s discouraged mothers from hugging children (the head of the American Psychological Association went so far as to recommend only one kiss per year). Parents magazine praised a psychologist whose books, according to Blum, foresaw "a baby farm where hundreds of infants could be taken away from their parents and raised according to scientific principles."
But soon thereafter, things began to change. The psychoanalyst Rene Spitz produced sensationalist, disturbing movies of infants growing up in what amounted to solitary confinement in New York orphanages. Chicago pediatrician Joseph Brennemann discovered that babies sometimes died of what could only be called loneliness.
In Britain, the psychologist John Bowlby published his theory of infant attachment, which argued that a strong, affectionate tie to a caregiver is essential to a child's mental health and development. And in Wisconsin, Harlow performed a series of cruel but dramatic experiments showing that lonely baby monkeys would repeatedly return to a lifeless doll he called the "iron maiden" for affection, even when the device was rigged to stab them or hurl them away or blast them with compressed air. Children, it became clear, desperately needed parental attachments for healthy development.
With these ideas gaining traction, Congress in 1961 created a federally funded foster-care program that shifted kids out of orphanages and into family homes. By 1965, only 4 percent of American orphans remained in institutions.
But attachment theory did not influence child welfare programs in the Soviet Union and the Eastern Bloc. And so, while Americans and western Europeans largely abandoned institutional care for orphans, Russians continued relying on it. At the time of a 1998 Human Rights Watch report, hundreds of thousands of children were committed to orphanages in Russia, while only several hundred lived in family-size foster-care settings.
Of course, many factors contribute to the plight of Russian orphans, including inadequate family-planning resources, underfunding of child welfare services and widespread alcoholism. And a culture of adoption has never taken off in Russia: Of an estimated 800,000 Russian orphans today, only about 15,000 are adopted each year, half of them by foreigners.
Child-development experts have long believed that foster care is better than orphanage care, but until recently, the data were lacking. Then in 2007, Charles Nelson, the Harvard professor working in Romania, published in Science the results of a groundbreaking study in which 136 infants were placed either in foster care or orphanages. Foster care produced significantly higher IQ scores, and the younger the child at the time of placement, the bigger the difference. "Institutional care is bad for kids," Nelson told me. "The fact is that institutional care always does worse than family care." (This may be one reason that adoptees from South Korea, which has a well developed foster-care system, have fewer mental disabilities than Russian adoptees.)
Washing, feeding and dressing needy children, it turns out, is the easy part. What child welfare institutions in Russia and other parts of the former Soviet Union still need help with is providing environments that nurture strong, loving attachments between children and their caregivers. As history shows, that's a lesson that can take a long time to learn.
But recently, the glacial pace of transition to family-based care has thawed. Kemlin Furley, UNICEF's deputy representative to Russia, sees increasing commitment from top officials to the principle that, as she said, "kids should be in families." She points to President Dmitry Medvedev's creation of a program that has promoted foster care in provinces such as Perm. As a result of these changes, tens of thousands of children have moved to foster care in the past few years.
Femmie Juffer, a Dutch sociologist who has reviewed studies involving hundreds of thousands of adoptees, told me that, across cultures, "pre-adoption adversity" predicts later behavior problems. Perhaps some good may yet come from young Justin Hansen's story, if it highlights the adversity faced by many Russian orphans who have never known a family's love.
Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts medical school, is Slate's health-care columnist and a contributing editor at Parents.